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1782A (10)
WORKERS'COMPENSATION DECLARAl10N 76A883 �a�e, qppL�CATIOf� FOR ELECTRICAL PERMIT�---� {�� I here6y affirm that I have a certificate of consent b self insure, cE-8o6G or a eertiticate ot'Workers'Compensation msurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY u copy there f See.3800.Lab.C.) ,/� PoIiCy NdF�CAfnPary N�LJ�i/�f//_7L_ FOR APPUCANT TO FILL Ml.. - ;. JOB - / p ❑ �Certilied e is here6 furnished. �i�v. EACH�� NO. � .. �E_ �DRESS�[p�d� /�. .oPY� . , Y . ,-� �. - New Residentiat 81dgs.&Poo�p� - ��� -�� •Ce-'ied�copy is filetl with the'eounty�buiWing insPection 1&2•Famity.Sq.Ft.�SC_ S — `�.. LOCALfTI'��� �� � . //// • rtme . - �� �' � - � � � / Multi-family Sq.FL �� py�NER oR �'//�� �j✓/� CRO55 ST. Date� � �Applicant��"��`-� ResidenY�al Swimming Pools . .. . . - .. . ., � . . . . . . . � . . . .. - ---' FlRM NAME �' CEFffIFICATE OF EXEMPTION FROM WORKERS'� � � � \ -' nnna �7 �] � -��-�� ���.: COMPENSATION INSURANCE � ��� � .. - ���ets:Rec—L'ght—Sw.— .-._ .. - qpDREss- •(/• X � .aC (Thb�seLtbn need not be completed B lhe wak Invdved by the Frst 20. � ' '.�1r� �permil is fw one hundred dollare(5100)or kss.)_� . � Total No. Additionai �� -�� -- ��� �� -'-- � � t,.ivfNL�L �70v2 Tel.No���' .I certify�that�in the pedormance of.the work for which this permit ' - _ � . ._ . e�NCMECK _ , APPLICANT is.iasued,I shall rot empby any person in arry manner so as to � become sublect to the Workers'Compensation Lews. ,• .�, L'ghtirg Fixtures Fret 20'-� � - --� � � �- �- ADDRESS - --- - �---� - . .. . . .. . .. .. . ... .� �- Addtional �. , _ .. . . .. . . .. _. Total No. CITY . . . . . . Tel.No. Date -ApD�ioant -- � �- � ' Fxed Appiiances Not Over 7 HP NOTICE.:TO.APPLJCANT: If,,after�making"this Certilicate o( PER""ir �� .. �� .E�mption,you should become subject to the Workers'Compensation _ .. .Range_Heater__DW. _ APPLICnNT . ._ .. .. _ ...... ... . _. �,provisions of the Wbor Code,yov must forthwith comply�with such Oven_Dryer_W.M._ . ADDRESS X�� �provisions or this Pertnit shall 6e deemed revoked. � � __ _ .Top..—FAU _..W.H._._. ._._ _.. . CITV�/NO�J�T����7eC No��6f�0� . .LICENSED CONTR4CTORS DECLARAl10N. Hood—Fan _Other_ I luveby affirm that I am licensed under provisions oF Chapter 9 -__ --�- Dis:--�Room�Air CoM.'�-_� ---- ��- - - --� �-� � uCENSEOR � ________ ��a�i+�i' (commencirg with Section 7000)of Division 3 ot the 8usiness and � P neG.NUMeef7 i.�'� v Professions Code,and rtry license is in fuil lorce and eftecl. .Power Apparatus 8 Large Appliances� -� ' oismiCr No. aaoces5eo av ._ .. ... ._. . . .. ...__ . .. O , Size 8 Type HP,KW,KUA or KVAR - ` �0.�d'n /�-7) �+ D Licensa Number' �v� Lic.Class ` � � ��� � � � � -� - - � - - - - --- -- �U Up to 1 Incl. � FINAL -C/�i�-j�-/.7��.,..., , -/ Over 7,to.1 D.Incl. DATE//��9. � Contractor � Date- ` -' �- / ..-., - . -...VALIDAI'ION .... _ Over 10 to SO IncL � FINAL V ,❑._I am exempt urder Sec. -��� -��• - ���� ` - --- -Ovet 50 to 100 inc.- gy.._- '' � - --. _.._.._._.. _ . __ B.SP.C.for thfs reason Over 100 � ��� ....___ ._ ._.. .._._. . . _ . . . . . -.. 'Services.5wtid..M6C8Paneltioaids.. . .._.. .. ..._.__.. ____.... .._ _ -.__.___ _____.__.. ...___ . _ ... Z - � � �Date:�-�� 0-200 Amp.Under 600 V � " Siqnature -. _._-2D1�-1000 Amp.Under 600 V-._ ... . -. . ---. . . . ....__.. . .:...._.. . . .. __. . . .. ... .__. ._ ._ . .. . .. . . ._. . ._. ' � . . Ovcr 1000 Amp.ar Over 600 V �� ���C' �� ExempCan for Reg.Maint.Elect. ���� �����-�- ��' � ��� - -• - -� - .. _.._. ._.. ._...- . - -.-. __�r.- ... , . � SINGLE FAMILY �� -� _. Temp.Power Pole 8 Mpurtenances_._..._ � ._.. _ . . .._ ..._ .... . ._ �� ° � ° `� HOME OWNER-BUILDER DECLARATICN Sign with One Branch Circuit � I hereby affirm that I am exempt irom ihe Contrector's License Law � � a 9 Q.J 1 for ihe following reason(Section 7031.5,Business and Professions " ��tional Sgn Branch Cirevits - ���• -� - -- �--�--�-�-�- -- � �--�- - --------_ Codel: . � . • e G G.�!i� ❑ � Misc:Conduits 8 Conductors � � � � ' ` � �� � "�---� --- � � `� ��� - � - -��-���- � � I,as owner ot the property,wi�l do tho work and the structum Other�See Complete Fee Schedule)_ O 9,2 C G�G is not intended or ofterea tor sale(Section 704a,Business . . _._. . � _ _ .. . ._ ard Protessbns Codel. .. �-- -� .... - CONSTRUCTION LENDING AGENCV � '� �"�-� -�-""" ���"'- �- ��---' '--- I hereby aifirm that there is a construction tendirg agency for the � performance ot the vrork for which this permit is issued(Sec.3097, - �pEAMR FEE"-"-�"- '����---� � ' � � (Su6-Totaq � � � � � �- -- �-�--- � ���-� - �� Civ.C.). ..-' PLAN CHECKING FEE� . .. . `.. -_ -- ..... � . _. .. . . . _. .._.__ . Lender's Name ' . - . ..... ... � - PERMR�ISSUINGFEE-. . . - . - .---. .... _ . . - .- -. Lender's Address � /} � . . � _ . �. . . ..., � I certiFy that I have read lhis applbation and state that the above -- -�TOTAL FEE._.._._ __._. . ... �_ . /�3 . , __ - ... .___- _ _ __. .. ... . � -- � - - .._ ._. .. informatbn is correct.I agree to comply wilh ali County ordinances and State laws regulattrg Electrical wiring,and hereby autFrorize..___.. .. .. _._. __. .. .. . . _ . . . . . . .... . . .. _ . . ....... _..._ . .._._ __.._ . ._. . representatives ot this County to enter upon the above-menYroned - �� � P�ty for fnspectlo�ses. . ��� . -��SEE REVERSE FOR EXPLANATORY LANGLIAGE -�------ /� n�/1_ ___ _ . .__ _.. .._ _ SLS «��o n _ . .. 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